NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is to be on bed rest for two weeks. What should the nurse do to prevent atelectasis?
Correct Answer: A
Rationale: Deep breathing and coughing expand the lungs, preventing atelectasis in bedridden clients. Foot exercises, stockings, and ROM prevent other complications but not atelectasis.
Question 2 of 5
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Sweating and confusion indicate hypoglycemia, a serious complication of insulin lispro, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 90 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
Extract:
A client is admitted to the neurology unit for a myelogram.
Question 3 of 5
It would be MOST important for the nurse to ask which of the following questions?
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct-dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the Test to replace the CSF lost during Test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)
Extract:
Question 4 of 5
The nurse is providing home care to an elderly woman who had a cerebrovascular accident (CVA) and has right-sided hemiplegia. She is living with her daughter. Which observation indicates that the family needs more instruction?
Correct Answer: D
Rationale: Placing the chair on the right (paralyzed) side hinders safe transfers; it should be on the unaffected left side, indicating a need for further instruction.
Question 5 of 5
The nurse is caring for a client with a history of deep vein thrombosis who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0) for DVT, increasing bleeding risk, requiring dose adjustment. Options B, C, and D are normal: PTT is unaffected, platelet count 200,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.